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Paediatric Urotherapy Training

Paediatric Urotherapy Training. Frances Shit NS, MSc (Hons), ET, Dept. of Surgery, PWH, CUHK HKSAR. Urinary Incontinence in Children. Urine leakage in a child from 5 years of age Leakage occurs on a regular basis (> once / week ) and sufficient to cause social inconvenience.

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Paediatric Urotherapy Training

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  1. Paediatric Urotherapy Training Frances Shit NS, MSc (Hons), ET, Dept. of Surgery, PWH, CUHK HKSAR

  2. Urinary Incontinence in Children • Urine leakage in a child from 5 years of age • Leakage occurs on a regular basis (> once / week ) and sufficient to cause social inconvenience

  3. Urinary Incontinence in Children Night (Nocturnal Enuresis) Day Functional Organic Structural / anatomical Anomalies Neurogenic bladder dysfunction

  4. Urotherapy • Treatment / training aimed at normalizing the bladder function by active cooperation ( learning & practice ) of the child, based on evaluation of the function ( Anna-Lena Hellstrom, 1990)

  5. The design of a Paediatric Urotherapy Nurse Clinic in Hong Kong

  6. Paediatric Urotherapy Nurse Clinic • Aims: To provide bladder rehabilitation training for children who present with daytime and / or night time enuresis • Services started since June, 2001 in Li Ka Shing Surgical OPD, PWH • HA nurse clinic accreditation - 2009 • Session: every Wednesday a.m. • Training: includes out-patients & in-patients programme

  7. Referrals from different clinics General Paed. Surgery Nocturnal Enuresis Paediatric Urology Private clinic Screening Paed. Urotherapy Nurse Clinic

  8. Ideal candidates • > 5 years old children • Children with day time urinary symptoms +/- nocturnal enuresis • No neurological / structural / urological problems

  9. Assessment • Medical & surgical history, UTI episodes • Medications, urinalysis • Physical examination of abdomen, genital areas, spine Bladder diary Bed wetting chart Bowel function diary

  10. Radiological investigations • Ultrasonography of urinary tract • Spine X-ray • Magnetic Resonance Imaging • Micturition Cystometric Urethrogram ( MCU ) • Renal Scans • Uroflowmetry, bladder scan for PVR • Urodynamic studies

  11. Urotherapy training program • Individualized program based on assessment information, signs & symptoms of voiding disorders • Aim: to help the child to get control over its voiding

  12. Urotherapy training program • Standard urotherapy training • Bowel management program • Enuretic alarm training • Biofeedback therapy • Neuromodulations

  13. Standard urotherapy training • Cognitive and behavioral training • Scheduled drinking, time voiding • Optimal toilet posture • Active relaxation exercise • Uroflow biofeedback with bladder scanner measurement • Double voiding strategies if large PVR

  14. Bladder man • Cognitive and behavioral training • anatomy & physiology of urinary system • behavioral modification of voiding style

  15. Optimal toilet posture

  16. Snoopy chart Bladder volume training • Encourage drinking • Random urine output once daily / alt. day • Set target

  17. Dry Pie • Enuresis record for children • 5 weeks in a pie chart

  18. Reward chart • Color 1 bar for a dry day or dry night • Reward for achieve a pre-set target

  19. Uroflow biofeedback with bladder scanner measurement

  20. Uroflow biofeedback • Visualize uroflowmetry curve during voiding • Learn to correct flow curve • Check PVR

  21. Urotherapy training program • Standard urotherapy training • Bowel management program • Enuretic alarm training • Biofeedback therapy • Neuromodulations

  22. Urotherapy training program • Standard urotherapy training • Bowel management program • Enuretic alarm training • Biofeedback therapy • Neuromodulations

  23. Nocturnal Enuresis • The failure to achieve bladder control by a given age, usually defined as 5 years ,with wetting occur during sleep without organic disease

  24. Nocturnal Enuresis Primary • The child has never been dry for a significant length of time Secondary • Loss of control after a significant period ( 12 months or more ) of being dry, beyond the age of 3 years

  25. Enuresis Alarm • Offer a choice of type ( body worn vs bed pad ) • Regular follow up and feedback FAILURE • Review reason why e.g. alarm breakdown, failure to wake, turning off alarm, parental intolerance

  26. Advantages: high initial and long term response rate safety of equipment Dis-advantages: fail to awake disrupted sleep for the rest of family possible technical failure Enuresis Alarm

  27. Urotherapy training program • Standard urotherapy training • Biofeedback therapy • neuromodulations

  28. Biofeedback training • Aim: to help develop greater awareness & voluntary control over the pelvic floor muscles during voiding • Out-patient or in-patient individualized training

  29. Urotherapy training program • Standard urotherapy training • Biofeedback therapy • Neuromodulations

  30. Neuromodulation • Transcutaneous electrical nerve stimulation ( TENS) • Electrodes bilaterally put over S3 level • Stimulation of the pudendal nerve to activate the pelvic floor and modulates innervation of the bladder, sphincter and pelvic floor • Clinical changes: • Decrease number of wet episodes • Decrease urge intensity

  31. Urotherapy Protocol • Urotherapy protocol for detrusor overactivity ( DO) • Urotherapy protocol for dysfunctional voiding ( DV) • Urotherapy protocol for DO & DV

  32. Conclusions • The development of the Urotherapy Clinic can improve children’s micturition parameter by intensive voiding re-education • Great support can be provided to child & families during the training process

  33. Thank You

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